Healthcare organizations in the United States face many challenges besides treating sickness and giving medical care. One big and complicated issue is dealing with social determinants of health (SDOH). These are conditions that affect how people are born, grow up, live, work, and get older. They include things like economic policies, social habits, political systems, education, housing, transportation, and the neighborhoods people live in. Research, especially from groups like the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO), shows that these things often affect health more than genes or even healthcare access.
For medical practice leaders, owners, and IT managers, knowing how to work well with local communities to find and fix SDOH is very important. By building partnerships with communities and using new data tools and technology, healthcare groups can do more to improve public health, lower health differences, and move toward health equity—the idea that everyone should have the chance to be as healthy as possible.
Social determinants of health are often grouped into five main areas, as shown by the CDC’s Healthy People 2030 initiative:
Each area has parts that affect health results. For example, safe and affordable housing, dependable transportation, clean air and water, access to healthy food, and chances for exercise all belong to neighborhood and built environment. Economic stability includes income, jobs, and food security, while social and community context involves social inclusion, community support, and facing discrimination.
Studies show that poverty is linked to worse health and a higher chance of dying early. The CDC says that SDOH affect health in many ways. For example, people living in poor communities may find it hard to get good healthcare, have more chronic illnesses, and score lower on health knowledge tests. Also, problems like racism can limit access to education, jobs, and housing, causing ongoing health differences in racial and ethnic minority groups.
Healthcare groups in the U.S. are learning that treating medical problems alone isn’t enough. To make patient health better and improve the health of communities, these groups must think about social factors in care plans and outreach work.
One key way is working closely with community members and organizations. Public health groups, clinics, hospitals, and medical offices should invite local helpers—like social service agencies, housing offices, schools, faith groups, and neighborhood groups—to share ideas about community needs.
Bringing these groups together helps healthcare organizations understand local problems better. For example, community talks might show that transportation issues stop patients from going to appointments or that fresh food is hard to find, causing bad nutrition. Talking with community members makes sure plans match real problems and not guesses.
Data is very important for finding and fixing SDOH. Healthcare groups can combine different data sources, including public health databases, patient records, and maps called geographic information system (GIS) maps, to find areas that need help. The CDC’s PLACES data and GIS maps are tools that track things like housing quality, pollution levels, and access to parks or grocery stores.
By layering many kinds of data—like environmental justice information, economic stats, and health results—groups can find local gaps and make better plans. Using data helps save resources and guides policy decisions.
Healthcare groups that take part in making health policies can make lasting changes to social determinants. They can support changes like zoning laws for affordable housing, transportation help, or better school nutrition programs to improve health over time.
Also, many federal and state programs now give money to groups working on SDOH through value-based care or population health programs. Working well with communities is often needed to get this money.
The CDC’s Racial and Ethnic Approaches to Community Health (REACH) program started in 1999 and shows how different groups working together can focus on SDOH. REACH partners with racial and ethnic minority communities to lower chronic diseases by working on tobacco use, access to healthy food, places for exercise, and health care connections.
Important parts of REACH are building coalitions, involving communities, and coordinating with healthcare, local government, and other groups. This matches strategies that healthcare providers in the U.S. can use when working on SDOH in their communities.
Though it is clear that dealing with social determinants is important, some challenges make it harder:
Even with these problems, working on SDOH is key to lowering health differences in the U.S. For example, life expectancy can differ by as much as 18 years between rich and poor groups.
Healthcare groups are finding that artificial intelligence (AI) and automation tools can help find and manage social determinants of health. These tools can make work easier, cut down on paperwork, and improve patient communication.
Companies like Simbo AI offer AI-powered front-office phone services that answer many calls smoothly. For healthcare, it is very important to talk with patients quickly and clearly—whether for making appointments, checking for social needs, or giving information about support services.
AI can handle simple calls, give custom answers, and connect people to social support without needing extra staff. This helps patients and lets healthcare teams focus more on medical care and community work.
AI can help screen patients for social needs by checking answers given in automated calls, chatbots, or intake forms. Linking these tools with electronic health records (EHR) helps providers find patients who may need help with housing, food, transport, or mental health services.
Automated data collection and analysis cut down on manual work and make tracking social determinants more accurate. AI can handle big amounts of data from surveys, patient feedback, and public health sources. This helps managers see trends, plan resources, and check how well programs work.
Platforms like Simbo AI can link phone automation with scheduling, care coordination, and community resource systems to make work smoother. This helps keep care continuous and supports health programs that focus on population health and value-based pay.
Using AI automation lets healthcare groups overcome some work problems when dealing with social determinants, making things run better and still keeping good patient care.
For medical practice leaders, healthcare owners, and IT managers who want to work on social determinants, these steps offer guidance:
Health differences in the U.S. show why it is important for healthcare groups to work with communities and address social determinants. In 2021, the CDC director called racism a public health threat. This points to the system barriers that need changing.
Improving social determinants leads to healthier people, fewer avoidable illnesses, lower healthcare costs, and better health fairness. For healthcare leaders and IT staff, including community work and technology in daily tasks is becoming necessary, not optional.
Research over many years shows that fixing healthcare access alone is not enough when money and social issues affect health so much. A planned, team-based, data-informed, and tech-supported way can help close these gaps and improve health for communities served by U.S. healthcare groups.
By building good community partnerships, using data and policies well, and applying AI-based workflow automation, healthcare groups in the United States have a chance to answer social determinants of health in a strong way. This full approach can help lower health disparities and improve well-being, especially for groups that have been underserved or face higher risks due to social factors.
SDOH are the nonmedical factors influencing health outcomes, including conditions in which people are born, grow, work, live, worship, and age. They encompass forces like economic policies, social norms, and political systems shaping daily life and health.
SDOH are a priority for the CDC because they significantly influence health outcomes, even more than genetics or healthcare access. Addressing SDOH helps achieve health equity and improve population health outcomes.
SDOH contribute to health inequities by creating disparities in access to housing, education, employment, and healthcare, particularly impacting communities of color due to historical and systemic racism.
Healthy People 2030 highlights five SDOH areas: healthcare access and quality, education access and quality, social and community context, economic stability, and neighborhood and built environment.
Organizations can convene community members to identify concerns, integrate diverse data sources for strategy development, influence policies, leverage funding, and collaborate on innovative solutions to address SDOH effectively.
REACH targets chronic diseases in racial and ethnic minority communities by reducing tobacco use, improving access to healthy foods, promoting physical activity, and connecting people to clinical care.
SDOH influence patient outcomes by impacting living conditions, access to resources, and social factors that contribute to risks like poverty and racism, leading to worse health outcomes and higher premature death rates.
Racism is recognized as a public health threat because it drives health inequities by limiting access to socioeconomic resources, increasing exposure to risks, and adversely affecting community health outcomes.
CDC encourages integration of multiple data types, including public health data, GIS maps, environmental justice data, and community asset information to better understand and address local health needs.
By targeting SDOH, public health efforts can create equitable access to housing, education, and healthcare, reduce chronic disease rates, and implement policies that promote healthier environments and lifestyles.
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